Information Collection

Website Customer Service Satisfaction Survey - EHR

IC 203096 under ICR 201205-0917-002 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Document Name Document Type
Form 0917-0036-04 Website Customer Service Satisfaction Survey - EHR Form
0917-0036-04 IHS Customer Satisfaction Survey; EHR Survey Monkey - VI Final OMB Form No. 0917-0036-04.pdf Form
Mini Supporting Statement for OMB Form No. 0917-0036-04.pdf OMB Form No. 0917-0036- EHR Survey Monkey - VIRTUAL Mini-Supporting Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Website Customer Service Satisfaction Survey - EHR	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0917-0036-04	IHS Customer Satisfaction Survey; EHR Survey Monkey - VIRTUAL	Final OMB Form No. 0917-0036-04.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
OMB Form No. 0917-0036- EHR Survey Monkey - VIRTUAL Mini-Supporting Statement	Mini Supporting Statement for OMB Form No. 0917-0036-04.pdf	07/09/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.